MEN: How often do you have EIGHT or more drinks on one occasion?WOMEN: How often do you have SIX or more drinks on one occasion?

How often during the last year have you been unable to remember what happened the night before because you had been drinking?

How often during the last year have you failed to do what was normally expected of you because of drinking?

In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down?

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Are you allergic to any medications?(please state which ones)

What is your ethnicity?

What is your first language?

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